대한안과학회지 2008 년제 49 권제 11 호 J Korean Ophthalmol Soc 2008;49(11):1711-1716 DOI : 10.3341/jkos.2008.49.11.1711 고주파를이용한얼굴주름치료효과 신재호 1 전찬 2 우경인 3 김윤덕 3 경희대학교의과대학동서신의학병원안과학교실 1, 한림대학교의과대학한강성심병원안과학교실 2, 성균관대학교의과대학삼성서울병원안과학교실 3 목적 : 얼굴주름에대한고주파의치료효과에대해알아보고자하였다. 대상과방법 : Glogau photoaging scale 에서 type Ⅲ, Ⅳ 주름을가진 50 세이상의환자 23 명을대상으로 Surgitron Dual Frequency 를이용 1 주간격으로 4 회실시후 1 주, 1, 3, 6 개월에경과관찰하였다. 객관적향상정도는사진을통해두명의관찰자가판정하였고, 주관적향상정도는설문을통해주름향상정도, 환자만족도, 추후다시시술을원하는지조사하였다. 결과 : 사진평가에서 3 개월까지현저한주름의향상이대다수의환자에서관찰되었다. 자가평가도사진평가와유사하게 3 개월까지높게나타났다. 눈주위가가장치료효과가좋았고, 시술후회복기간은짧았으며, 특별한합병증은없었다. 결론 : Surgitron Dual Frequency 를이용한얼굴주름치료는비교적단기간효과적이었다. 치료에의한위험이없고, 회복기간이짧아서비교적간단히시술할수있는치료방법이었으며주기적으로반복하는것이효과적일것으로생각된다. < 대한안과학회지 2008;49(11):1711-1716> 피부주름은피부노화에따른가장흔한미용문제로기존에사용되고있는피부주름개선을위한비수술적치료방법으로는화학박피, 미세박피술 (microdermabrasion), 레이저를이용한치료등이있다. 이런방법들의공통적인기전으로는손상받은조직에열을가하거나제거함으로써피부밑에있는아교질 (collagen) 을수축시키고새로운아교질형성을촉진해서피부를팽팽하게하여주름을개선시키는효과가있는것으로알려져있다. 하지만이런치료들은피부및표피에직접적인영향을주기때문에회복기간이필요하다는것과합병증의위험이있다는단점이있다. 1 이런합병증을최소화하기위해진피층에만자극을주는치료가소개되었는데이런방법으로레이저를이용한 non-ablative skin resurfacing, 고주파를이 < 접수일 : 2008 년 3 월 5 일, 심사통과일 : 2008 년 11 월 4 일 > 통신저자 : 김윤덕서울시강남구일원동 50 성균관대학교삼성서울병원안과 Tel: 02-3410-3561, Fax: 02-3410-0074 E-mail: ydkimoph@skku.edu * 본논문의요지는 2007 년대한안과학회제 98 회추계학술대회에서구연으로발표되었음. 용한 Thermage 등이소개되었다. 이방법들도합병증의위험과회복기간이어느정도감소된효과는있으나여전히치료결과예측과효과는부족한측면이있다고알려져있다. 2 고주파가피부주름개선시키는기전은고주파에의해발생한열이초기에피부아교질을수축시키고이후수주간에걸쳐점차적으로아교질재형성에의한것으로알려져있다. 3 Surgitron Dual Frequency TM RF (Ellman, USA) 은독자적인용량결합 (capacitive coupling) 을이용해레이저나, Thermage 에비해피부및표피손상없이진피층에열을더효과적으로많이전달할수있는장점이있는장비로더좋은치료효과와합병증의위험이적을것으로생각된다. 이에저자들은고주파를사용하는 Surgitron Dual frequency 를이용하여얼굴주름에대한고주파의효과, 얼굴에서가장효과가좋은부분, 고주파치료의안정성에대해알아보고자하였다. 대상과방법 Glogau photoaging scale 에서 type Ⅲ, Ⅳ 주름을가진 50 세이상의환자를대상으로하였고, 얼굴주름을개선시키는다른치료를이전에받은경우치료대상에서제외하였다. 정해진양식의동의서를받고 1711
신재호외 : 고주파를이용한얼굴주름치료효과 Surgitron Dual Frequency TM RF (Fig. 1A) 를이용하여 1주간격으로 4회실시한후술후 1주, 1, 3, 6개월에경과관찰을실시하였다. 시술은 Surgitron Dual Frequency TM RF의 mode를 cut/coaguation mode로맞추고 power setting을 15~20으로한후고주파에너지를피부에직접전달할수있도록시술부위에따라 5, 10, 15, 20 mm 크기의반구형핸드피스 (Fig. 1B) 를사용하였다. 먼저손에시술해서환자가약한열감을느끼는정도로 power setting을맞춘후시술받을부위에 RF cool gel을바르고기계를작동하기전에반구형핸드피스를치료하고자하는부위에원형으로돌리면서환자와술 자가준비가되면페달을밟아서기계를작동시켰다. 핸드피스를원형으로돌리면서환자가약간의열감을느낄때까지시술하였고동일한부위에 2~3 회반복하였으며, 얼굴전체를시술하는데평균시간은 15~20 분정도였고시술중환자가약간의화끈거리는느낌을호소하는정도외에특별한합병증은없었고, 시술중마취나피부소독은필요하지않았다. 경과관찰은시술후 1 주, 1, 3, 6 개월에실시하였다. 눈둘레근, 이마근, 입둘레근의작용에의해생기는얼굴주름의개선정도를평가하기위해눈주위, 이마와미간, 뺨과입주위세부분으로나누어부위간의차이와각부분의객관적, 주관적향상정도를주름이완전히없어지는것을 100% 로하여향상정도에따라 5 단계 (0: 0%, 1: 1~25%, 2: 26~50%, 3: 51~75%, 4: 76~100%) 로나누어비교하였다. 객관적향상정도는시술전후사진을통해두명의관찰자가판정하여사진평가점수를정하였다. 평가를위한시술전후사진은동일한카메라로동일한장소에서동일한조도에서촬영하였다. 주관적향상정도는환자설문을통해주름향상정도를역시 5 단계로나누어주름향상자가평가점수를결정하였고, 환자만족도는대단히만족, 만족, 보통, 불만의 4 단계로나누어비교하였으며, 추후계속시술을원하는지여부를조사하였다. 주름향상자가평가점수와사진평가점수는독립표본 t 검정을이용하여통계적차이를비교하였다. 결 과 Figure 1. Surgitron Dual Frequency TM shape handpieces (B). RF (A) and dome 대상환자는 23 명이었고남자가 2 명, 여자가 21 명이었다. 연령은 50~69 세로평균 58.2±5.3 세였다. 사진평가점수의평균은 1 주, 1, 3, 6 개월때눈주위는 2.13, 1.91, 2.04, 1.2 였고, 이마와미간은 1.74, 1.6, 1.7, 1.0 였으며뺨과입주위는 1.74, 1.65, 1.7, 1.13 이였다 (Fig. 2A). 주름향상자가평가점수의평균은 1 주, 1, 3, 6 개월때눈주위는 2.13, 2.01, 2.0, 1.17 였고, 이마와미간은 1.61, 1.61, 1.73, 0.96 였으며, 뺨과입주위는 1.83, 1.87, 1.83, 1.01 이였다 (Fig. 2B). 객관적평가인사진평가점수와주관적점수인주름향상자가평가점수에서눈주위가제일점수가좋았으며, 세부분모두술후 1 주일때가점수가가장높았다. 세부분사진평가와주름향상자가평가점수모두 6 개월때많이감소하였지만눈주위주름향상자가평가점수를제외하곤통계적으로유의한감소를보이지는않았다. 또한각경과관찰때마다사진평가점수와주름향상자가평가점수간의유의한차이는없었다. 얼굴각부분의사진평가점수와주름향상자가평가점수는 1712
대한안과학회지 2008 년제 49 권제 11 호 Figure 2. Photography assessment scores (0=0%; 1=1-25%; 2=26-50%; 3=51-75%; 4=76-100%). (A) and self estimation scores (0=0%; 1=1-25%; 2=26-50%; 3=51-75%; 4=76-100%). (B) There was no statistical difference between the two scores. 3 개월까진 50% 이상개선을보이는환자들도많았으나, 6 개월경과관찰때는주름개선효과가많이감소하였으며 (Fig. 3) 호전이유지되는환자들도대부분경미한호전을보였다 (Table 1). 환자만족도조사에선세부분모두 3 개월경과관찰까진치료에만족하는환자의비율이제일많았으며눈주위에대한시술에서치료만족도가가장높은것으로나타났다 (Table 2). 3 개월때만족이상을보이는환자가눈주위에서 78%, 이마와미간에서 74%, 뺨과입주위에서 61% 였다. 시술받은부위에약한발적과열감이있었으나시술 2~6 시간후에는자연히사라졌으며, 경미한눈꺼풀부종을호소하는환자가두명있었으나역시시술 5~6 일후에는자연히호전되었다. 또한부가적인효과로피부주름의개선뿐아니라모공축소, 피부광택증가등의피부자체향상도시술초기모든환자에서관찰되었고치료하루가지나면화장이가능하였다. 치료효과가사라진후동일치료를선택하겠다는환자가 91.3% 로비교적높게나타났다. 고 찰 피부주름은자외선등의노출로피부가노화됨에따라피부각질층의증가, 정상적인표피세포극성의손실, Figure 3. Before (A) and 1 (B), 3 (C) and 6 months (D) after four sessions of radiofrequency. Periocular and glabellar rhitides improvement by photography was a grade 2 (26~50%) at 1 month, grade 3 (51~75%) at 3 months and a grade 2 (26~50%) at 6 months. Perioral rhytides improvement by photographs was a grade 1 (1~25%) at 1 month, grade 2 (26~50%) at 3 months and a grade 1 (1~25%) at 6 months. 기저막의비후, 멜라닌세포의응괴 (clumping) 등의원인으로발생하는것으로최근노인층의증가에따라개선을위한여러가지치료들이시도되고있다. 4,5 피부주름개선을위한비수술적인방법으로는화학박피, 미세박피술, 레이저를이용한박피술등이있다. 이런치료들의공통기전은노화에의해손상된조직을제거하거나열을가해초기에피부아래층의아교질을수축시키고이후섬유화와아교질합성을촉진시킴으로써피부를팽팽하게하고주름을개선시킨다. 하지만이런방법들은표피에손상을주기때문에회복기간이필요하다는것과피부발적, 피부색소변화, 감염, 피부반흔, 피부염등의합병증의위험, 그리고결과예측이어렵다는단점이있다. 6-8 이런합병증을줄이기위해표피에는영향을주지않고진피층에만자극을주는치료가소개되었는데이런방법으로처음소개된것이레이저를이용한 non-ablative skin resurfacing 이다. 1713
신재호외 : 고주파를이용한얼굴주름치료효과 Table 1. Wrinkle improvement after treatment by photography assessment and self estimation 1 week 1 month 3 months 6 months 0 (0%) 1 (4%) 2 (9%) 2 (9%) 6 (26%) 1 (1-25%) 6 (26%) 6 (26%) 5 (22%) 8 (35%) Photography 2 (26-50%) 7 (30%) 7 (30%) 6 (26%) 6 (26%) assessment 3 (51-75%) 7 (30%) 8 (35%) 10 (44%) 3 (13%) Peri-ocular area 4 (76-100%) 2 (9%) - - - 0 (0%) 1 (4%) 1 (4%) 1 (4%) 6 (26%) 1 (1-25%) 6 (26%) 3 (13%) 5 (22%) 9 (39%) Self estimation 2 (26-50%) 8 (35%) 14 (61%) 12 52%) 6 (26%) 3 (51-75%) 5 (22%) 3 (13%) 3 (13%) 2 (9%) 4 (76-100%) 3 (13%) 2 (9%) 2 (9%) - 0 (0%) 2 (9%) 2 (9%) 2 (9%) 7 (30%) Photography 1 (1-25%) 9 (39%) 10 (44%) 10 (44%) 10 (44%) 2 (26-50%) 6 (26%) 6 (26%) 7 (30%) 4 (17%) assessment 3 (51-75%) 5 (22%) 5 (22%) 4 (17%) 2 (9%) Glabellas & 4 (76-100%) 1 (4%) - 1 (4%) - forehead 0 (0%) 4 (17%) 4 (17%) 4 (17%) 7 (30%) 1 (1-25%) 8 (35%) 5 (22%) 5 (22%) 11 (48%) Self estimation 2 (26-50%) 5 (22%) 10 (44%) 8 (35%) 4 (17%) 3 (51-75%) 5 (22%) 4 (17%) 5 (22%) 1 (4%) 4 (76-100%) 1 (4%) - 1 (4%) - 0 (0%) 3 (13%) 3 (13%) 2 (9%) 7 (30%) Photography 1 (0-25%) 9 (39%) 9 (39%) 8 (35%) 8 (35%) 2 (26-50%) 5 (22%) 5 (22%) 8 (35%) 6 (26%) assessment 3 (51-75%) 3 (13%) 5 (22%) 5 (22%) 2 (9%) Peri-oral area 4 (76-100%) 3 (13%) 1 (4%) - - 0 (0%) 5 (22%) 4 (17%) 4 (17%) 7 (30%) 1 (0-25%) 5 (22%) 5 (22%) 6 (26%) 9 (39%) Self estimation 2 (26-50%) 5 (22%) 7 (30%) 7 (30%) 5 (22%) 3 (51-75%) 5 (22%) 4 (17%) 2 (9%) 2 (9%) 4 (76-100%) 3 (13%) 3 (13%) 4 (17%) - Table 2. Treatment outcome by patients satisfaction 1 week 1 month 3 months 6 months Very satisfied 3 (13%) 3 (13%) 4 (17%) 2 (9%) Peri-ocular area Satisfied 16 (70%) 17 (74%) 14 (61%) 8 (35%) Minimal Satisfied 2 (9%) 1 (4%) 3 (13%) 11 (48%) Dissatisfied 2 (9%) 2 (9%) 2 (9%) 2 (9%) Very satisfied 2 (9%) 2 (9%) 4 (17%) 1 (4%) Glabellas & Satisfied 15 (65%) 15 (65%) 13 (57%) 6 (26%) forehead Minimal satisfied 3 (13%) 3 (13%) 4 (17%) 14 (61%) Dissatisfied 3 (13%) 3 (13%) 2 (9%) 2 (9%) Very satisfied 2 (9%) 2 (9%) 3 (13%) 1 (4%) Peri-oral area Satisfied 12 (52%) 13 (57%) 11 (48%) 7 (30%) Minimal satisfied 7 (30%) 6 (26%) 9 (39%) 13 (57%) Dissatisfied 2 (9%) 2 (9%) 2 (9%) 2 (9%) 사용되는레이저종류에는적외선 (1,320 nm) 을사용하는 CoolTouch, intense pulsed light (585~ 1,100 nm) 를사용하는방법, Nd:YAG (1,064 nm) 를사용하는방법등이있다. 9,10 이런방법들은합병증은어느정도개선하였지만효과가만족스럽지못하고 일정하지못한단점이있다. 얼굴주름개선을위해고주파를처음이용한보고는 Fitzpatrick et al 2 에의해처음보고되었고눈주위주름개선효과가 80% 정도있었다고보고하였다. 고주파의피부주름개선효과의기전은초기에고주파에의 1714
대한안과학회지 2008 년제 49 권제 11 호 해생성된열이물이나아교질에의해흡수되어피부의바탕질에직접영향을주고, 이후이런자극들이상처치유반응등에영향을주어세포매개체나성장인자의형성을촉진시키는것으로가정할수있는데, Zelickson et al 3 이 2004 년에보고한바에의하면고주파치료직후전자현미경으로관찰한결과여러부위에서콜라겐섬유직경의증가와경계의소실이관찰되었고, 치료 7 일후에 Northern blot 으로분석한결과 Collagen typeⅠ RNA 의발현이증가하였다고보고한바있고이런가정을뒷받침한다고생각된다. 본연구에서주름개선효과가얼굴세부분중눈주위가제일개선효과가좋았는데이것은눈주위피부가제일얇기때문에고주파의아교질에대한영향이제일잘나타났다고생각된다. 객관적평가인사진평가점수보다주관적평가인주름향상자가평가점수가약간씩더좋은것으로나타났는데이것은평가항목엔포함되지않았지만고주파가주름개선뿐아니라피부자체향상효과도있었기때문으로생각된다. 본연구에서주름개선효과가대부분유지된 3 개월때까지사진평가에서 91% 의환자가주름개선이나타났고이것은고주파를이용한다른연구 3,11-13 에서치료효과가나타나는빈도가 75~80% 정도였는데비해더좋게나타났지만, 다른연구에서치료효과가 6 개월까지지속된것에비해본연구에선 6 개월때치료효과가많이감소하였는데이것은치료횟수가부족하였거나본연구에서심한주름을가진환자가더많았고환자연령이더높았기때문으로생각된다. 얼굴피부를다시젊어지게만드는치료에서가장중요한점은효과와더불어합병증이없어야하고회복기간이짧아야한다는점이다. 본연구에선치료후특별한합병증이전혀없었고, 회복기간이매우짧았다는점에서본치료의큰장점이라할수있지만, 환자및치료부위에따라다양한개선정도를보였는데이점은치료예측이라는측면에선본치료가가진한계라고생각된다. 결론적으로얼굴주름에대한 Surgitron Dual Frequency TM RF 를이용한고주파치료는효과적이었고, 최소침습적이고, 안전하였으며최소한의회복기간이필요한치료였다. 또한시술이비교적간단하고 시술에의한통증이나합병증이없어서주름치료에경험이적은안과의사들에게도유용한방법이될수있을것으로생각된다. 추후치료반응이좋은사람들과나쁜사람들간의관련인자의차이, 적절한치료횟수및장비 setting, 다른치료와병합치료의효과에대한연구가필요할것으로생각된다. 참고문헌 1) Holck DE, Ng JD. Facial skin rejuvenation. Curr Opin Ophthalmol 2003;14:246-52. 2) Fitzpatrick R, Geronemus R, Goldberg D, et al. Multicenter study of noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg Med 2003;33:232-42. 3) Zelickson BD, Kist D, Bernstein E, et al. Histological and ultrastructural evaluation of the effects of a radiofrequencybased nonablative remodeling device: A pilot study. Arch Dermatol 2004;140:204-9. 4) Green HA, Drake L. Aging, sun damage and sunscreens. Clin Plast Surg 1993;20:1-6. 5) Fisher GJ, Wang Z, Datta SC, et al. Pathophysiology of premature skin aging induced by ultraviolet light. N Engl J Med 1997;337:1419-28. 6) Monheit GD, Chastain MA. Chemical peels. Facial Plast Surg Clin North Am 2001;9:239-55. 7) Freedman BM, Rueda-Pedraza E, Waddel SP. The epidermal and dermal changes associated with microdermabrasion. Dermatol Surg 2001;127:1031-33. 8) Fitzpatrick RE. Maximizing benefits and minimizing risk with CO2 laser resurfacing. Dermatol Clin 2002;20:77-86. 9) Sadick NS. Update on non-ablative light therapy for rejuvenation: A review. Lasers Surg Med 2003;32:120-8. 10) Hardaway CA, Ross EV. Non-ablative laser skin remodeling. Dermatol Clin 2002;20:97-111. 11) Ruschiani A, Curinga G, Menichini G, et al. Nonsurgical tightening of skin laxity : A new radiofrequency approach. J Drugs Dermatol 2007;381-6. 12) Burns AJ, Holden SG. Monopolar radiofrequency tissue tightening-how we do it in our practice. Lasers Surg Med 2006;575-9. 13) Friedman DJ, Gilead LT. The use of hybrid radiofrequency device for the treatment of rhytides and lax skin. Dermatol Surg 2007;33:543-51. 1715
신재호외 : 고주파를이용한얼굴주름치료효과 =ABSTRACT= Effect of Radiofrequency Device for the Treatment of Facial Rhytides Jae Ho Shin, M.D. 1, Chan Jeon, M.D. 2, Kyung In Woo, M.D. 3, Yoon Duck Kim, M.D. 3 Department of Ophthalmology, East-West Neo Medical Center, KyungHee University College of Medicine 1, Seoul, Korea Department of Ophthalmology, HanKang Sacred Heart Hospital, Hallym University, College of Medicine 2, Seoul, Korea Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University College of Medicine 3, Seoul, Korea Purpose: To evaluate the effect of radiofrequency device for treatment of facial rhytides. Methods: Twenty-three patients of more than 50 years of age with Glogau photoaging scale type Ⅲ, Ⅳ were included in this study. A Surgitron Dual Frequency device was used for facial rhytides, and a total of four treatment sessions spaced one week apart were performed. Clinical assessment was performed at one week, and at one, three, and six months after the last treatment session. The degree of objective & subjective improvement was determined using a five-step graded scale. Objective improvement was determined by two blinded assessors using before and after photographs. Subjective improvement was determined by questionnaire about rhytides improvement, patient satisfaction and prospect for another treatment session. Results: Significant improvement in facial rhitides was observed in the majority of patients until three months after treatment according to photography assessment. Self-estimation scores paralleled the photography scores and thus were also high until 3 months after treatment. Treatment of the periocular area was most effective. The procedure was associated with minimal downtime, and therewas no serious complication. Conclusions: treatment for facial rhitides using the Surgitron Dual Frequency device is effective in a relatively short time. This technology is a relatively easy treatment method because of the minimal downtime and minimal risk associated its use, making periodic repetition efficient for treating facial rhytides. J Korean Ophthalmol Soc 2008;49(11):1711-1716 Key Words: Facial rhytides, Radiofrequency Address reprint requests to Yoon-Duck Kim, M.D. Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine #50 Ilwon-dong, Gangnam-gu, Seoul 130-710, Korea Tel: 82-2-3410-3561, Fax: 82-2-3410-0074, E-mail: ydkimoph@skku.edu 1716